Form 0917-0036 We Care Survey, Blackfeet Community Hospital.

Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery: IHS Customer Service Satisfaction and Similar Surveys

OMB No 0917-0036 We Care Survey Survey Blackfeet Tribe

We Care Survey, Blackfeet Community Hospital.

OMB: 0917-0036

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Form Approved

OMB Form No. 0917-0036

Expiration Date:

BLACKFEET COMMUNITY HOSPITAL

"WE CARE SURVEY"


How Do You Feel About the Services


Outstanding


Above Average


Average


Below Average


Unsatisfactory

Provided to You Today in the:


DEPARTMENT



Healthcare Provider Rating:



1. Please Rate the Nurse







2. Please Rate the Doctor/Provider







3. Rate Overall Service provided







Hospital-Wide Rating


1. Inside Appearance







2. Outside Appearance









Hand Hygiene: Circle Yes, No or N/A (Not Applicable)


Did staff clean hands with soap or alcohol rub:

Nurses

Medical Staff

Other Staff


1. BEFORE touching patient

Yes No N/A

Yes No N/A

Yes No N/A


2. AFTER touching patient

Yes No N/A

Yes No N/A

Yes No N/A


3. Didn’t notice

Yes No

Yes No

Yes No



Did you notice anything during your visit that you felt was unsafe? No Yes if so, explain

on back.

Comments (use back of form if needed)









According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0917-0036. This time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the times estimate(s) or suggestions for improving this form, please write to U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention, PRA Reports Clearance Officer.

File Typeapplication/msword
File TitleBLACKFEET COMMUNITY HOSPITAL
Authorllucke
Last Modified ByClay, Tamara (IHS/HQ)
File Modified2015-05-11
File Created2015-05-11

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